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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "'` '' FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o COMPLETE THIS FORM FOR EACH FACILITY/SITE �'"•�^=�" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION V-i PE ANENTLY CLOSED SITE I"+• ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE v 0 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cn FACILITY/SITE NAME _ CARE OF ADDRESS INFOATION (L LE15 Ern. Zeer ADDRESS / // NEAREST CROSS STREET ✓9mxinjse 0 PAAINBENIP ❑ STATE AGBXY 'e Q/�i1 f'� ei &?ifn 6AlCN. omdwM O LCO r�AGwc ❑ RnBw AGBia CITY NAME �+W i'' STATCA ZLE 75.€ O nNE M.W13/AREA C C� TYPE OF BUSINESS: F-12 DISTRIBUTOR El PROCESSOR ✓Box R INDIAN EPA ID N Y 1 'I J RESERVATION or //6w M of TANK'F ❑ 1 GAS STATION [:]3 FARM OTHER TRUST LANDS ❑ 6w ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME( ST,FIRST) I PHONE N WITH AREA DE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHT NAME(LAST,FIRST) O PHOj E N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE Al WITH AREA CODE 11. PROPERTY OWNER INFORMATION &3ADDRESS 6— (MUST BE COMPLETED) NAMES Ic A _s o u L{_—rs CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓sox to indicate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME,.•1!v`1 A�� •� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS V I/Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: u2n II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY N FACILITY ID If K of TANKS at SITE [-u = = 101012- IZI,61610jpo CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE•WITH AREA CODE 15-M I L-A 3-2— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIDNCODE CENSUS TRACT SUP VVVISOR• STRICT CODE BUSINESS P gNFILED ND ❑ DAM FILED Z3 L CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: TINS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY 1